International Journal of
Environmental Research
and Public Health
Opinion
E-Cigarette as a Harm Reduction Approach among
Tobacco Smoking Khat Chewers: A Promising Bullet
of Multiple Gains
Saba Kassim 1, * and Konstantinos E. Farsalinos 2
1
2
*
College of Dentistry, Taibah University, Al-Madinah Al-Munawwarah 43353, Saudi Arabia
Onassis Cardiac Surgery Center, Sygrou 356, Kallithea 17654, Greece; [email protected]
Correspondence: [email protected]; Tel.: +966-053-555-8878
Academic Editor: Paul B. Tchounwou
Received: 4 January 2016; Accepted: 15 February 2016; Published: 19 February 2016
Abstract: Khat chewing/use, a green leaf with amphetamine-like effects is socially integrated in
the Middle East and Africa. Khat chewing is often associated with tobacco smoking and occurs in
closed places, such as a family home setting where the smoke-free laws cannot be implemented.
Tobacco cigarette smoking among khat chewers is a significant concern, but there is also second-hand
exposure to smoke at home or in places where khat users gather. Evidence suggests that e-cigarettes
represent a significantly less harmful form of nicotine intake. Evaluating the effects of e-cigarettes
among khat chewers could be important in understanding the impact of e-cigarettes as a harm
reduction approach, with the potential to reduce the health risk associated with smoking.
Keywords: khat; tobacco smoking; e-cigarettes; nicotine
1. Introduction
The chewing/use of the amphetamine–like khat leaf from Catha edulis is widespread and
socially ingrained in the Middle East and East Africa and their diaspora communities world-wide.
Khat chewing has become a national and international public health concern [1] and has recently gained
popularity globally [2]. Khat is very often used with tobacco smoking [3]. Khat chewers are either
daily tobacco smokers or smoke tobacco when chewing khat [3]. The use of tobacco by khat chewers
represents a clear public health concern [4]. There is a significant prevalence of tobacco smoking among
adult and school children khat chewers [4] with gender difference in mode of tobacco use: women
often smoke waterpipe tobacco whereas men often smoke tobacco cigarettes [5]. An alarming elevation
in the level of tobacco dependence associated with higher khat dependence, and very high levels of
carbon monoxide among smoking khat chewers have been observed [3]. The estimated of tobacco
use among khat users versus smoker none khat users was found higher [4] although the difference in
smoking dependence between khat users and non-users has not been established.
The reason that khat users smoke tobacco is mainly to enhance the stimulant effects of khat [3],
indicating some interaction between nicotine/tobacco and the chemicals present in khat that awaits
identification [3]. The session of khat-use often occurs in closed places, such as a family home setting
or meeting places for immigrants [6,7] where the smoke-free laws cannot be implemented. Thus,
besides the risks associated with smoking among khat chewers, there is also second and third-hand
(environmental) exposure to the toxicants present in cigarette/waterpipe smoke.
Khat chewing is an integral part of different social aspects, and attempts to control its use failed
in khat-originating countries [8]. However, efforts should be made to reduce the adverse effects of
smoking in khat chewers. Although many khat users reported they had thought about and had
Int. J. Environ. Res. Public Health 2016, 13, 240; doi:10.3390/ijerph13020240
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attempted to quit khat and tobacco use [5], there is no evidence on the effects of using approved
smoking cessation methods in this population. Moreover, access to and willingness to visit smoking
cessation clinics is expected to be limited, considering that most khat users are immigrants or living
in low income countries (e.g., Yemen) where implementation of tobacco control and availability of
tobacco cessation services are scarce. One of the methods of promoting smoking reduction or cessation
would be by switching from inhalation of combustible products to a non-combustible nicotine-delivery
product, such as the e-cigarette. The emergence of the e-cigarette as a harm reduction product that
could decrease smoking related disease has currently received great attention among regulators
and the scientific community. Evidence suggests that, although not absolutely safe [9], it represents
a significantly less harmful form of nicotine intake [10,11] and can become an important tool for
smoking reduction [12] and cessation [13], even in highly-dependent smokers (based on Fagerström
Test for Cigarette Dependence) with very high daily cigarette consumption [14]. Thus, e-cigarettes
could be used as a harm-reduction approach, with the main goal of reducing the adverse health
effects of smoking in the population of khat users. However, the acceptability and subsequent effects
of e-cigarette use has not been tested among tobacco smoking khat chewers. E-cigarettes could be
used as an alternative to smoking for this population, due to their ability to deliver nicotine (which
is needed to enhance khat effects) as well as substitute the sensory-motor aspects of the smoking
behavior. Additionally, their use could potentially reduce second and third-hand exposure to the
tobacco cigarette smoke observed in rooms where khat-chewing sessions are performed.
2. Future Research Directions
Future research should consider evaluating the use of e-cigarettes in khat chewing sessions as
a specific need within the broader general need for research regarding the safety and efficacy of
e-cigarettes [15]. Different research questions related to tobacco use along with khat chewing should
be tested, including the following:
1.
2.
3.
4.
5.
Can e-cigarettes enhance the effect of khat use similarly to tobacco smoking?
Can e-cigarettes effectively reduce the need of khat chewers to smoke, leading to smoking
reduction or cessation?
Can e-cigarettes have an effect in reducing khat use?
Will khat chewers who use waterpipe (predominantly women) accept the use of e-cigarette products
that resemble waterpipe smoking (there are electronic shisha products with design similar to
waterpipe which use e-cigarette liquid and produce aerosol similar to conventional e-cigarettes)?
Will partial or complete switching from tobacco smoking to e-cigarette use result in reduced
biomarkers of toxins exposure (nitrosamines, polycyclic aromatic hydrocarbons, etc.) in khat chewers?
3. Conclusions
In khat chewing countries, e-cigarettes could become a promising bullet that might reduce the
health risks of smoking khat chewers and the second and third-hand exposure of people living around
them. That would be consistent with the Framework Convention on Tobacco Control and Tobacco
Treatment (FCTC) goals of treating tobacco dependence and protecting people from second-hand
exposure while taking into account national circumstances and priorities [16]. With the current opinion
letter we propose the development of a new research agenda, focusing on the efficacy of e-cigarette
use on tobacco smoking khat chewers.
Author Contributions: Saba Kassim conceived the idea and wrote the first draft of the manuscript.
Both Konstantinos E. Farsalinos and Saba Kassim wrote the manuscript and approved it.
Conflicts of Interest: Saba Kassim declares no conflict of interest. Two of the studies by Konstantinos E. Farsalinos
were performed using unrestricted funds provided to the institution by e-cigarette companies in 2013.
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© 2016 by the authors; licensee MDPI, Basel, Switzerland. This article is an open access
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(CC-BY) license (http://creativecommons.org/licenses/by/4.0/).